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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201086
Report Date: 01/05/2022
Date Signed: 01/05/2022 12:11:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:K & J RESIDENTIAL CARE HOME-HAYWARDFACILITY NUMBER:
019201086
ADMINISTRATOR:BROWN, ELTONFACILITY TYPE:
740
ADDRESS:838 W. SUNSET BLVD.TELEPHONE:
(510) 363-9387
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:5CENSUS: 0DATE:
01/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Elton Brown/AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing re-inspection and met with Elton Brown, administrator.

License application was reduced from six (6) total capacity to five (5), all non-ambulatory. Perimeter fence was installed after the initial pre-licensing inspection on September 14, 2021. Facility was re-inspected by the fire department and fire clearance was granted on December 20, 2021.

LPA toured the facility with administrator. All deficiencies observed during initial pre-licensing inspection have been corrected except the posting of Theft and Loss Policy. LPA observed tile on the front yard not leveled.

Administrator to do the following and submit pictures by Friday, January 7, 2022.
1. Post facility's Theft and Loss Policy.
2. Have the tile leveled.

LPA discussed the requirement for N95 respirator fit testing of staff. LPA and administrator agreed that prior to admission of first resident(s), staff will be fit tested and record to be submitted to LPA.

Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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